Written evidence from Tribal Group PLC
(COM 28)
Tribal Group is one of the few private sector
organisations with significant experience of supporting NHS commissioners
to deliver improved health and better patient outcomes and is
a leading supplier operating within the Framework for External
Support to Commissioners (FESC).
Tribal works with commissioners in long term
transformation programmes using advanced tools and techniques
to deliver better health services at lower cost. We typically
enter into long term risk and benefit share contracts so that
we have a direct stake in the speed and impact of our initiatives.
We have major contracts with a number of Primary Care Trusts (PCTs)
across England, the largest of which is in excess of £20
million for the nine Primary Care Trusts in South Central.
We therefore submit this evidence to the Health
Select Committee to comment on the challenges to NHS commissioners,
the opportunities for reform and the implementation challenges
that arise from the White Paper "Equity and Excellence: Liberating
the NHS". We have also attached two case studies demonstrating
practical support for clinical led commissioning.
IMPROVING COMMISSIONING
We believe that the NHS needs strong commissioners
to drive improvements in the health of the population and to achieve
the necessary improvements in productivity and quality and enable
individual citizen to make informed choices about the care that
they receive and hold the NHS accountable for the outcomes achieved.
Currently, commissioners do not have the capacity
or capability to drive the changes required to deliver better
patient outcomes and achieve the required improvements in productivity
and efficiency. While World Class Commissioning has made progress,
we believe it lacked the teeth to address poor performance more
directly and it led to overly bureaucratic and "staged"
responses to the assurance process.
In our view, most commissioners in the NHS still
lack the basic information, technology and skills to make the
necessary impact.
Where we have succeeded in innovative public/private
sector partnership models, it has been achieved through:
— Establishing the right balance of managerial
and clinical input to commissioning decisions.
— Using advanced information management
and technology services at scale.
— Introducing proven improvement techniques
from the UK as well as internationally.
— Challenging pre-conceptions about the
scale of improvement and the pace of change that can be achieved.
— Driving change through established programme
management techniques and organisational development.
CLINICAL ENGAGEMENT
IN COMMISSIONING
We believe it is critical that clinicians are
actively involved in all parts of the commissioning cycle so that
they confirm the needs of the population, the relative shares
of investment in health promotion and health care services and
the support the management of health care providers to ensure
that intended outcomes are achieved.
We are disappointed that PCTs have not made
the progress required to develop Practice based Commissioners
(PbC). While PbC groups have typically concentrated on providing
new models of primary and community services, too few have actively
been engaged in meaningful commissioning activities that change
health care services for the better.
In one of our contracts in NHS Ashton, Leigh
and Wigan (ALW), we saw that no progress in PbC had been achieved
when we began our partnership in September 2008. Within 18 months,
we had worked with local clinicians to establish six viable PbC
groups, introduced new tools and techniques, devolved management
support from the PCT, established PbC business plans and developed
6 new major service pathways covering Stroke, ENT, Breathlessness,
Diabetes, Rheumatology and Ophthalmology. These pathways will
improve patient outcomes and deliver in excess of £3 million
savings per annum. Simultaneously, we have provided analytical
tools and services which enable these groups to review the activity
provided and manage the performance of local health care providers.
These changes would not have been possible without:
— The unique partnership between the public/private
sector.
— The determination to equip clinicians
to play an active role in commissioning decisions.
— The collective understanding that practice-based
commissioning needed to bring together clinicians and managers
so that the respective skills could be harmonised.
— The vision and imagination of new clinical
leaders and their desire to work side-by-side with commissioning
managers from the PCT.
As these PbC groups continue to mature and develop,
they are able to understand variation in health care provision
in all settings (including primary care).
The private sector brought vision, energy, drive
and commitment to the development of clinical commissioning in
ALW. We believe that the models developed in NHS Ashton Leigh
and Wigan provides strong evidence for the effectiveness of primary
care clinical involvement in all commissioning activities.
The six PbC groups that work together in ALW
are evolving into GP-led Commissioning Consortia. While they are
already recognising that they need to work together to achieve
meaningful impact on patient care, they are only just beginning
to understand their responsibilities for productivity improvement
and patient accountability. We would suggest that GP-led Commissioning
Consortia, if constituted correctly, should provide greater opportunities
for local people to engage in decisions about health and health
care and the way resources are applied to address their needs.
TRANSITIONAL ARRANGEMENTS
Strong transitional support will be required
to support the creation of GP-led Commissioning Consortia and
maintain the focus on productivity and quality. Beyond more detailed
information about each of the reforms, we believe that the transition
to 2013 will require:
— Strong management that works closely
with the emerging clinical leaders to establish the new models
of commissioning.
— A clear vision of the shape and style
of GP-led commissioning and how they will access the necessary
management skills, tools and technologies that will be required.
The White Paper has caused a degree of organisational
turbulence in PCTs and Strategic Health Authorities (SHAs) and
this could threaten the pace of reform and in particular, the
creation of the new GP-led Commissioning Consortia.
In our view, embryonic consortia will need to
quickly establish the right balance of "buy, share, build"
improvement strategies that will be needed to make progress alongside
PCTs. They will need to access independent support and advice
about the merits of different options and to support them as they
demonstrate their new capabilities to the NHS Commissioning Board.
While PCTs and SHAs are safeguarding existing
commissioning arrangements and productivity plans, the new NHS
Commissioning Board will need to accredit consortia and safeguard
patients interests while new arrangements evolve.
We believe that consortia will need to be statutory
organisations that have a clear blueprint. While they are GP-led,
they will need to be comprised of clinical and business acumen
and be capable of designing and implementing new service models.
Again, we believe that the private sector has
a role to play in using innovation to deliver management support,
information technology and organisational development at scale.
Within South Central, Tribal is delivering a wide range of commissioning
enablement services (CES) to nine PCTs that will provide continuity
as well as critical business services for evolving commissioning
consortia. Economies of scale have enabled these PCTs to receive
world class tools and techniques at a fraction of the cost if
they had procured individually.
Tribal works in partnership with the public
sector and this means that in all of our contracts, there is considerable
provision for staff development and skills transfer. Our commissioning
partnerships are some of the most successful examples in the NHS
and we have used our resources to help many NHS commissioners
develop new skills, tools and techniques. As we look to the future
and the needs of GP-led Commissioning Consortia, we again look
forward to working alongside NHS management resources and supporting
them in their new roles. We believe this will minimise redundancy
costs, protect local knowledge and enable consortia to be self
sufficient in the medium term.
CASE STUDIES
NHS Ashton Leigh and Wigan
NHS Ashton Leigh and Wigan (NHS ALW) entered
into a three year strategic partnership with Tribal Group (Tribal)—one
of a small number of national pilots under FESC. This programme
is helping to catalyse the redesign of health and social care
services so that local people can access the right services, in
the right place, at the right time.
One of the five partnership objectives is "to
improve financial management and generate savings which will be
re-invested back into patient care". Significant tangible
achievements have been made in the first year of this partnership
on a range of fronts, including identified savings of over £3.5
million in 2008-09 to be reinvested in rebalancing health expenditure
and improving health outcomes. To the end of August 2009, the
contract has achieved:
— Over £3 million savings through
new pathways of care that shift services from acute hospitals
to more convenient settings in the community.
— Over £2.2 million savings through
acute invoice validation (AIV), reductions in baseline contracts
and the introduction of new contract conditions.
— £0.35 million identified savings
(recurring) in statin and Proton Pump Inhibitor (PPI) medicines
management by switching patients from high to low-cost equivalents
(PPIs are ulcer inhibiting drugs).
— £1.2 million projected savings in
April 2010 through the introduction of reduced tariffs.
— Tribal is also confidently forecasting
£1 million savings from AIV in 2009-10.
The total value of the contract is £4.8
million, of which £2.3 million will be funded from "guaranteed"
savings delivered by Tribal which results in a net "worst
case" cost to the PCT of £2.5 million. The contract
states that the first £2.3 million of savings are to be paid
to Tribal in full. Savings over and above the £2.3 million
will be split on a basis of 75% to the PCT and 25% to Tribal.
This sum is capped at £10 million, so that after this value
is reached, the PCT retains 100% of the additional savings generated.
Any recurrent savings beyond the first 12 months (after they have
been realised) will be retained 100% by the PCT.
One of the five partnership objectives between
NHS ALW and Tribal is "to apply international standards and
best practice that can benefit the residents of Ashton, Leigh
and Wigan". Working with the NHS ALW commissioning team and
primary care, Tribal has introduced new international best practice
tools and techniques, including the following:
— NHS ALW is the first PCT in the UK to
deploy the Johns Hopkins operational population risk profiling
tool (ACGs[7])
widely regarded as the leading edge population and risk profiling
tool in the world.
— The MCAP[8]
utilisation management tool, has been deployed to provide clinically-based
assessments of weaknesses in the health system and identify why
they occur; reviews have been completed for elective and non-elective
care and a productivity programme for the short and medium term
is now underway.
— Working with Public Health, Tribal have
completed world class health equity audits with Sheffield School
of Health and Related Research for COPD, CVD and, Diabetes.
Early findings have demonstrated that 40% of
unscheduled inpatients are in the wrong care setting. Introduction
of pro-active discharge planning on two pilot wards reduced length
of stay by two days.
Risk stratification found that a cohort of 4%
of the population who consume 40% of the healthcare resources.
A hospital at home service has been set up managing 100 patients
most of whom would otherwise be managed within the hospital setting.
This group is now being targeted for evidence-based disease and
case management models following the international best practice.
A re-ablement service has also been created for the frail elderly
and this is showing over 95% patient satisfaction and reduction
in social care costs. This is being linked to high-risk management
programmes through the developing community matron services.
COMMISSIONING ENABLEMENT
SERVICE, NHS SOUTH
CENTRAL PCT ALLIANCE
The nine PCTs of NHS South Central region (who
make up the South Central PCT Alliance) entered into a four year
strategic partnership with Tribal Group (Tribal) through FESC,
starting in January 2010, for the provision of a Commissioning
Enablement Service (CES). They spend £5.5 billion a year
on the health and wellbeing of the four million people in their
communities. Geographically they stretch from Milton Keynes in
the north to the Isle of Wight in the south, covering the counties
of Buckinghamshire, Berkshire, Oxfordshire, Hampshire and Isle
of Wight.
The region is, overall, relatively affluent
compared with the national average and therefore receives relatively
low funding allocations per head of population. There are however
local areas of relative deprivation and health inequalities eg
in part of Portsmouth, Southampton and Slough, compared with more
affluent areas such as Winchester and Wokingham.
The corollary to the relative prosperity of
the region is that funding allocations are below average. This,
at least in part, creates new challenges, including a constant
struggle to keep the regional health economy in financial balance.
The relative wealth of populations in South
Central is not matched by lower demands on the health system and
this has placed local commissioners in difficult financial positions
historically. Local people are typically very informed, influential
and demand the very best from the NHS.
In common with the rest of the NHS, commissioners
in South Central face a significant financial challenge over the
next five years. However, because South Central PCTs receive the
lowest per capita allocation in the NHS, as finances tighten
a significant funding gap will need to be addressed and the health
systems will need to be re-sized to meet this.
Driving improvements through evidence based
commissioning is central to the achievement of this goal. The
CES is designed to achieve a step change improvement in the information
and specialist analytics to underpin PCT commissioning by supporting
three key areas:
— Strategy—identifying the biggest
opportunities for improvement in quality, outcomes and productivity.
— Operational Planning—converting
strategy to delivery through credible, consistent and cohesive
commissioning programmes.
— Performance Management—achieving
and maintaining high performing health systems, using a complex
array of levers and system interventions.
The total value of the contract is £23
million, of which a percentage is dependent on Tribal identifying
£200 million of savings each year across the Alliance. To
provide the PCTs with the information, evidence, and skills to
drive out these savings Tribal has introduced new international
best practice tools and techniques, including the following:
— On the back of the work in NHS Aston
Leigh and Wigan, Tribal is deploying the Johns Hopkins operational
population risk profiling tool (ACGs[9])
widely regarded as the leading edge population and risk profiling
tool in the world
— The McKesson InterQual utilisation management
tool has been deployed to provide clinically-based assessments
of weaknesses in the health system and identify why they occur;
reviews have already been completed for non-elective care across
all the major Providers in South Central. Early findings have
demonstrated that over 30% of unscheduled inpatients are in the
wrong care setting, thus providing evidence for the health economy
to plan ahead for more appropriate distribution of services.
— Support for detailed QIPP (Quality, Innovation,
Productivity and Prevention) analyses.
— An Acute Invoice Validation Service that
provides the confidence for PCTs to conduct negotiations and arbitration
discussions in a clear and assertive manner, which is evidence
based, and which strengthens their position as an assertive commissioner
of services with their main acute providers.
— Initial strategy development and subsequent
detailed design to support the creation more meaningful pathway
improvement programmes that target single conditions (eg diabetes,
stroke, etc) as well as addressing the issue of co-morbidities
and those patients who require more complex services involving
multiple pathways.
— Development of tailored dashboards and
analytics presentation tools to allow PCT staff to investigate
and review evidence and knowledge captured in CES.
A key element of this contract is that the skills,
techniques and tools will be transferred across to the PCTs as
quickly as possible as time progresses to enable them to become
self sufficient in their use of CES.
October 2010
7 ACGs provide the ability to develop clinically-led
commissioning strategies on the basis of locality, disease, and
predicted resource consumption. This enables the PCT to visualise
and model the impact of "personalised" budgets for health
and social care. Back
8
MCAP uses the intensity of services delivered to the patient based
on the patient's severity of illness to accurately determine the
best level of care for patient placement. Back
9
ACGs provide the ability to develop clinically-led commissioning
strategies on the basis of locality, disease, and predicted resource
consumption. This enables the PCT to visualise and model the impact
of "personalised" budgets for health and social care. Back
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